Radical Abdominal Hysterectomy (Type III)

The five “types” of hysterectomy are defined in Chapter 30. Of these, radical hysterectomy differs from simple hysterectomy in that the parametrium, paravaginal tissue, and their lymphatics are widely resected to achieve negative tumor margins. Described in this section, type III (radical) hysterectomy is chiefly indicated for stage IB1 to IIA cervical cancer or small central recurrences following radiation therapy, or for clinical stage II endometrial cancer when tumor has extended to the cervix (Koh, 2015).

Type III radical hysterectomy is increasingly being performed by minimally invasive approaches. With these techniques, the principles of the abdominal operation are still applied. Namely, radical hysterectomy is a dynamic operation that requires a focused, consistent surgical approach but also significant intraoperative decision making. Familiarity with its concepts continues to be critically important in developing expertise in complex pelvic surgery.

PREOPERATIVE

Patient Evaluation

Radical hysterectomy is not appropriate for women with higher-stage cancers. Thus, accurate clinical staging is critical prior to selection of this surgery. Pelvic examination under anesthesia with cystoscopy and proctoscopy is not mandatory for smaller cervical cancer lesions, but the clinical staging described in Chapter 30 should be completed before proceeding surgically. To refine patient selection, for most patients with grossly visible cervical tumors, abdominopelvic computed-tomography (CT) or magnetic resonance (MR) imaging is also performed to identify nodal metastases or undetected local tumor extension. That said, there are limitations on what can be reliably detected preoperatively (Chou, 2006).

Consent

Women undergoing hysterectomy are specifically counseled regarding the loss of fertility. In those considering bilateral salpingo-oophorectomy (BSO), a discussion of menopause and hormone replacement is included and detailed in Chapter 43. The tone of the consenting process should reflect the extent of the operation required to hopefully cure or at least begin treatment of the malignancy. Moreover, a patient must be advised that the procedure may be aborted if metastatic disease or pelvic tumor extension is found (Leath, 2004).

Radical abdominal hysterectomy can result in significant morbidity from short- and long-term complications. These complications may develop more frequently in women with obesity, prior pelvic infections, and previous abdominal surgery, in whom surgery may be more difficult (Cohn, 2000). Of potential intraoperative complications, the most common is acute hemorrhage. Blood loss may reach 500 to 1000 mL, and transfusion rates are variable, but high (Estape, 2009; Naik, 2010). Subacute postoperative complications may include significant postoperative bladder or bowel dysfunction from surgical denervation (20 percent), symptomatic lymphocyst formation (3 to 5 percent), and ureterovaginal or vesicovaginal fistula (1 to 2 percent) (Franchi, 2007; Hazewinkel, 2010; Likic, 2008). With any cancer surgery, risk for venous thromboembolism (VTE) is also increased. Additionally, long-term effects on sexual function and other body functions are candidly ...